Your browser does not support JavaScript!

calculators
Member Education
forms and publications
news
about etf
frequently asked questions
contact etf
site map
related links
home
top of page
Wisconsin Department of Employee Trust Funds header image It's Your Choice 2019 Local Health Plan Insurance Program
members retirees employers governing boards careers at etf
skip to end of menu
2019 It's Your Choice - Local Health Plan Insurance for Employees and Retirees
Wisconsin Department Of Employee Trust Funds It's Your Choice 2019


Local Health Plan
Insurance for Employees
and Retirees
(PO6, PO16)


Breakdown of Your Costs by Plan Design

It’s Your Choice Local Health Program For Actives and Retirees without Medicare

Local Program Options 6 and 16

The table below lists costs for common services for each It's Your Choice plan design option. This is not a complete description of coverage, you can find that in the Certificates of Coverage.

 

 

Local Health Plan

Local Access Health Plan
in-Network

Local Access Health Plan
Out-of-Network

Annual Medical Deductible
Individual / Family

Counts toward out-of-pocket limit (OOPL)

$250 / $500

Medical deductible does not apply to office visit copays, preventive services or prescription drugs

After an individual within a family plan meets the $250 deductible, benefits apply as described below

$500 / $1,000

Medical deductible does not apply to prescription drugs

After an individual within a family plan meets the $500 deductible, benefits apply as described below

 

Primary Care Office Visit
Additional services such as lab work, X-rays, etc., count toward the deductible and coinsurance

Includes:
• Internist
• General Physician
• Family Practitioner
• Pediatrician
• Gynecologist / Obstetrician
• Nurse Practitioner
• Physician Assistant
• Chiropractor
• Physical / Occupational / Speech Therapy in an office visit setting


$15 copay per visit up to OOPL

Does not count toward deductible

After deductible: You pay 30% up to OOPL

Specialty Office Visit
Additional services such as lab work, X-rays, etc., count toward the deductible and coinsurance

Includes:
• Specialty Providers
• Urgent Care
• Vision Exam in an office visit setting


$25 copay per visit up to OOPL

Does not count toward deductible

After deductible: You pay 30% up to OOPL

Annual Medical Coinsurance
Applies to medical services except for office visit or emergency room copayments and preventive services

After deductible: You pay 10% up to OOPL

After deductible: You pay 30% up to OOPL

Medical Out-of-Pocket Limit (OOPL)

Individual / Family

$1,250 / $2,500

$2,000 / $4,000

Preventive Services
See healthcare.gov/preventive-care-benefits

Plan pays 100% Subject to the deductible and coinsurance

Illness/injury related services beyond the office visit copayment (if applicable)

After deductible: You pay 10% up to OOPL

Applies to medical services except for office visit or emergency room copays

After deductible: You pay 30% up to OOPL

Applies to medical services except for emergency room copays

Emergency Room
Copay waived if admitted as an inpatient directly from the emergency room or for observation for 24 hours or longer.

$75 copay per visit

Copay counts toward OOPL. Deductible and coinsurance may apply to services beyond the copay, up to OOPL

$75 copay per visit

Copay counts toward OOPL. Deductible and coinsurance may apply to services beyond the copay, up to OOPL

Transplants

After deductible you pay 10% up to OOPL

After deductible: You pay 30% up to OOPL

Mental Health/Alcohol and Drug Abuse

Additional services such as lab work, assessments, etc., are subject to deductible and coinsurance

Outpatient services: $15 copay per visit

Inpatient & covered transitional services: after deductible, you pay 10% up to OOPL

Outpatient, inpatient and covered transitional services: You pay 30% up to OOPL
Hearing aid (per ear)

Every three years:

Adults: After deductible, you pay 20% up to plan paid $1,000 (not to OOPL);

Dependents younger than age 18: After deductible, you pay 10% up to OOPL

Every three years: 

Adults: no benefit.

For dependents younger than age 18: After deductible you pay 30% up to OOPL

Cochlear Implants

Adults: After deductible you pay 20% for device, surgery for implantation, follow-up sessions (not to OOPL); for hospital charge for surgery you pay 10% up to OOPL

Dependents under age 18: After deductible, you pay 10% up to OOPL for all services

Dependents under age 18: After deductible, you pay 30% up  to OOPL for device, surgery, follow-up sessions
Skilled Nursing Facility (non-custodial care) After deductible: You pay 10% up to OOPL, 120 days per benefit period After deductible: You pay 30% up to OOPL, 120 days per benefit period
Home Health (non-custodial)

After deductible: You pay 10% up to OOPL, 50 visits per year

Plan may approve an additional 50 visits

After deductible: You pay 30% up to OOPL, 50 visits per plan year

Plan may approve an additional 50 visits

Physical/Speech/Occupational Therapy

$15 copay for office visits.

Additional services such as lab work, X-rays, etc. are subject to deductible and coinsurance up to OOPL

50 combined visits per year

Plan may approve an additional 50 visits per therapy type per year

After deductible: You pay 30% up to OOPL

50 visits per plan year

Plan may approve an additional 50 combined visits per therapy type per year

Durable Medical Equipment After deductible: You pay 20% up to OOPL After deductible: You pay 30% up to OOPL
Precertification for hospitalizations, high-tech radiology and low back surgery

Varies by plan

See plan descriptions and contact your plan

Contact WEA Trust
Referrals

In-network: Varies by plan

See plan descriptions and contact your plan

Out-of-network: Referral required

Not required
Oral Surgery After deductible: You pay 10% up to OOPL After deductible: You pay 30% up to OOPL
 

Local Health Plan

Local Access Health Plan
In-Network

Local Access Health Plan
Out-of-Network

Prescription Deductible None Must use in-network Pharmacy

Prescription Copay
Level 1

 

$5

Level 2
20% ($50 max)
Level 3

40% ($150 max)

Level 3 “Dispense as Written” or “DAW-1” drugs may cost more.

Level 4 Specialty $50 copay
(Must be filled at Lumicera or UW Specialty Pharmacies)
Preventive Plan pays: 100%, regardless of deductible

Prescription Out-of-Pocket Limit

Levels 1 & 2 - Individual / Family

 

$600 / $1,200

Level 3 - Individual / Family $6,850 / $13,700
Level 4 - Individual / Family $1,200 / $2,400

1 Must use an in-network pharmacy

 

Additional Prescription Drug Benefit Info:

“Zero Dollar” preventive drugs identified by the Affordable Care Act (ACA) are paid for 100% by the program. You can find a list here.

A list of fully covered contraceptives can be found here.

These lists may change at any time. You can find the most up-to-date lists here.

You can find a list of the current formulary here. You can also log into Navi-Gate® for members through this page to search for your prescription drugs on the formulary.

Some prescription drugs require a prior authorization for it to be covered by the program. A prior authorization is initiated by the prescribing physician on behalf of the member. Navitus will review the prior authorization request within two business days of receiving all necessary information from your physician. Medications that require prior authorization for coverage are marked with “PA” on the formulary. Learn more about drugs requiring prior authorization here.
Diabetic supplies and glucometers are covered; you will pay 20% coinsurance.
A 90-day supply of most maintenance medications can be purchased at your retail pharmacy. To take advantage of this program, you must have three consecutive claims already processed for that drug in the Navitus claims system immediately before the 90-day supply is requested. In addition, your doctor must write the prescription specifically for a 90-day supply. Three copayments are still required. More information can be found on the Navitus website or by calling Navitus Customer Care.
Serve You is the new mail order vendor. Up to a 90-day supply of Level 1 and Level 2 medications can be purchased for only two copayments through our mail order service.Level 3 medications may also be available for up to a 90-day supply, but you pay three copays, or the excess as described in the DAW-1 example, below. More detailed information can be found on the Navitus website, Serve You website or by calling Navitus Customer Care.
By splitting a higher-strength tablet in half to provide the needed dose, you receive the same medication and dosage while buying fewer tablets and saving on copayments. Medications included in the program are marked with “¢” on the Navitus formulary. Members may obtain tablet splitting devices at no cost by calling Navitus Customer Care.
(Level 4 Self-Injectables and Specialty Medications)
If you are taking a specialty medication, the Navitus SpecialtyRx Program is offered through both Lumicera Specialty Pharmacy and the UW Specialty Pharmacy for non-Medicare participants. Specialty medications are marked with “ESP” in the formulary.  To begin receiving your self-injectable and other specialty medications from the specialty pharmacy, please call Navitus SpecialtyRx Customer Care at 1-877-651-4943.
Coordination of benefits applies when, as determined by the order of benefit determination rules, you have primary coverage under another policy and Navitus is your secondary coverage. All claims need to be submitted to your other policy first. Navitus covers the remaining cost of any covered prescriptions up to the allowed amount under your Group Insurance plan. Coordination of benefits does not guarantee that all your out-of-pocket covered.

This does not apply to retirees with Medicare

Some doctors write prescriptions as “DAW-1,” or “dispense as written.” This means the pharmacist will fill the brand name drug as written and will not substitute an available generic equivalent.

Starting in 2019, you will pay more for “DAW-1” brand name level 3 drugs unless you cannot take the generic equivalent due to a medical need. If you have medical need, your doctor must submit an FDA MedWatch form to Navitus for the prescription. Have your doctor contact Navitus for the form.

The FDA MedWatch form must be submitted the first time you are prescribed the medication. Under normal circumstances, the form will be processed within 72 hours. For urgent/emergent situations, the form will be processed within 24 hours. After the form is submitted, it will stay on file with Navitus. Your doctor will not need to resubmit the form.

Without the form, you will pay the 40% coinsurance plus the cost difference between the brand name drug and its generic equivalent.

Example 1: Level 3 "DAW-1", No Medical Need for Brand Name Drug

Your doctor prescribes you BrandNameStatin and marks it as “DAW-1”. You do not have a medical need so your doctor does not submit the FDA MedWatch form

30-Day Supply Costs

Your Costs with Insurance

  • BrandNameStatin: $1,250
  • Generic equivalent: $5

Cost Before Insurance:

  • BrandNameStatin: $2,000
  • Generic equivalent: $900
BrandNameStatin Cost Calculation

$2,000 x 40% = $800 $150
You pay 40% of the original drug price. There is a limit of $150

$2,000 - $900 = $1,100
You also pay the cost difference between the brand name drug and the generic equivalent

$150 + $1,100 = $1,250

When having a brand name drug is not medically necessary, you can save money by getting the generic. In this example you’d save $1,245 each time you fill your prescription.

Example 2: Level 3 "DAW-1", Medical Need for Brand Name Drug

Your doctor prescribes you BrandNameStatin and marks it as “DAW-1”. The brand name drug is medically necessary because you are allergic to an ingredient in the generic equivalent. Your doctor submits the FDA MedWatch form to Navitus.

30-Day Supply Costs

Your Costs with Insurance

  • BrandNameStatin: $150

Cost Before Insurance:

  • BrandNameStatin: $2,000
BrandNameStatin Cost Calculation

$2,000 x 40% = $800 $150
You pay 40% of the original drug price. $800 is higher than the max, you are only responsible for $150.

Disclaimer:
Every effort has been made to ensure that this information is accurate, but may be subject to change. Please note revision dates located at the bottom of each page. In the event of conflicting information, federal law, state statute, state health contracts and/or policies and provisions established by the State of Wisconsin Group Insurance Board shall be followed.

This page was last modified on: 9/12/2018 7:11:07 AM